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APPL� Iv <br /> CATION ! ' <br /> SAN JOAQUIN COUNTY PUBLIC .HEAITH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O SOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby rade to San Joaquin County for a pera:t to construct and/or install the vork herein described. This <br /> application is made in cot*l:ance with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San <br /> r ` Joaquin County Public Health Services. <br /> 445 West Weber AvenueStockton 2.5 <br /> Job Address City Lot Sl:e/Acresga <br /> Stockton Savings .501 West Weber Avenue (249) <br /> Owner's Name Bank Address S-tocktm- CA 95202 <br /> Phone <br /> Kennedy/Jenks 303 Second St. , 10t .Floor (415) <br /> Gopwae!ar Consultants Address San FrancLsco.- CA 4 NO. Phone 243-2518 <br /> TYPE OF WELL/PUMP: ^NEW WELL u WELL REPLACEMENT Cl DESTRUCTION O Out of Service veil Q <br /> PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER CX( Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROIUNJborings) <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C? Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation 2 InC e5 Dia. of Wall Casing none <br /> C] Oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ none Specifications <br /> l'I Public Xothe(borings)XI Delta Depth of Grout Seal less than 15 ftryp, of Grout cement <br /> I 1 Irttgation Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair War, Done U Type of Pump <br /> m,p, State Work Dane _ <br /> �3 <br /> { Well Destruction ❑ Well Diameter Sealing Material 4 Depth Cement <br /> Depth Filler Material i Depth <br /> OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/AOOITION i I DESTRUCTION I l (No septic system permitted if public sewer <br /> available within 200 feet.) <br /> Installation will Residence_ Commercial_ other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fen. r table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well ation Property Lina <br /> LEACHING LINE Ci No. & Length of lines I length/size <br /> FILTER BED ❑ Distance to n Wali Foundation Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS L1 Distance to nearest: Weil Foundation Property Lina <br /> DIS L PONDS ❑ <br /> I horsey certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state laws, and <br /> rules and regulations of the San Joaquin Ccupty <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for +�ti*t+l�permit.is.issued, 1 shall not <br /> employ any parson g such manner as to become subject to workman's compensation laws of California."Coniractoes hiring or sul}contracting'signature <br /> certifies the following. "I certify that in the.peRormance of the work for which this permir is issued, I shall em la <br /> p y persona subjecrta wart, n'a compensa- <br /> tion Iowa of California." ._T, i <br /> The applicant must call for ail required inspections_ Complete drawing on reverse side. V <br /> Signed x_. ^ ' ,L _(RG #6153}ri,Ie. Hydrogeologist Date: 95 <br /> FOR;4£ ARTMENT USE ONLY <br /> r ..- <br /> 1!# Application Accepted by Date _ Area <br /> L : Pit or Grout Inspection by Data COIL' to <br /> iiisssffl { u�l - .� ,�_ <br /> f Additional Comments: EMRONIMENTAL ITEALTH 011' <br /> Applicant - Return all copies to: Saa Joaquin Countq Public Heal ]REQ .. PIERIMI <br /> Environmental Healtb\Permit/Services <br /> 445 N San Joaquin, P d Boa 2009, Stka, CA 95201 <br /> FEE AMOUNT OUEAMOUNT REMITTED Cx a RECEO @Y DATE PfRM1T'NO. <br /> I INFO CASH Nti <br /> �.24t„rv. sr Pale 13AEH tt.20 �'� <br />